Healthcare

• Introduction
• The development of cooperation in healthcare
• The evolving legal framework
• The organisation of cooperation
• The major issues in public health
• Prominent examples of cooperation

The major issues in public health

Several obstacles nevertheless hamper the emergence of cross-border health communities or even the development of cooperation. The biggest are legislative and regulatory and are overcome only partly or not at all by existing instruments. The organisation of health systems differs between countries, along with the amounts and rules of reimbursement and the selection of the care and drugs covered. These different elements, the consequence of different social protection choices, make the drawing together of two healthcare jurisdictions a complex exercise. The adoption of the European directive on cross-border healthcare nevertheless made it possible to remove some of these obstacles by laying down a common legal framework with respect to reimbursement.

Another major obstacle to cooperation relates to increased mobility of patients and health professionals. High patient mobility may unbalance the intake capacity of health services and have a negative effect on healthcare quality. Conversely, migration of healthcare professionals may lead to shortages in some regions and thus reduce access to healthcare. Foreign health professionals may not meet patient expectations, as their training, in particular that of nurses, differs between countries. There may also be language problems.

The introduction of competition between healthcare providers is another source of difficulties, especially in cross-border contexts. The introduction of hospital funding mechanisms based on volume of activity may oblige hospitals to attract more patients, including those cared for previously on the other side of the border.

The success of cross-border cooperation in healthcare thus depends on a number of joint actions being carried out in order to remove these obstacles. First, action needs to be taken so that healthcare and cross-border players complement one another more effectively. Indeed, the interaction between these players and their competences appears necessary for the future development of concrete actions and joint strategies in the area of healthcare in the territories concerned. Second, there needs to be a greater pooling of equipment to ensure that the healthcare offered along the entire border is comprehensive and fully operational, and to take account of the general context of public spending restrictions in Europe. Economies of scale could also be envisaged that would benefit patients and ensure better access to treatment, notably at local level. Lastly, the organisation of healthcare planning and the issue of reimbursement need to be the subject of ongoing joint consultations

ENGAGEMENT AT THE EU LEVEL

Moving towards increased engagement with the challenges of cross-border cooperation in health matters, the European Commission has published papers addressing cross-border healthcare in recent period, and has taken initiatives in favour of greater cooperation in this field.

Indeed, the European Commission adopted on 4 April 2014 a Community agenda specific to the improvement of Member States’ healthcare systems.

In June 2016, the Commission presented “The State of Health in the EU”, a two-year cycle addressing health in the Member States in order to increase knowledge on the subject at their level, as well as the more global level of the EU. This cycle was composed of four steps: the publication of a report “Health at a Glance: Europe 2016” (November 2016), specific profiles by country highlighting the characteristics of each Member State (November 2017, an analysis of these elements linking them with the EU agenda, at the end of the cycle the opportunity for a voluntary exchange of good practice that can be requested by the authorities responsible for health within the Member States (since November 2017).

In addition, the Committee of the Regions has recently highlighted on several occasions (November 2016, May 2017) the need to take into account health in the different areas of EU policy, with the assertion that these policies should be seen as an investment in the wellbeing of Member State populations, and not as a budgetary burden.

In September 2017 the Commission published a study entitled “European Cross-Border Cooperation on Health: Theory and Practice”. This publication, to which the MOT contributed, aims to give an account of cross-border cooperation in the field of health and the evolution of Europe’s role in health affairs generally, and by addressing 7 examples in Europe and examining in detail the French-Belgian situation.
In this field, cross-border cooperation impacts patients and healthcare professionals, as well as the healthcare systems themselves. The goal is to encourage the mobility of persons on either side of borders, by developing access to an “on the border” offering of quality healthcare through common services and facilities.

In March 2018 the European Commission published another study with the aim of providing a panorama of existing initiatives in the field of health. On this occasion 1167 projects have been analysed, in view of establishing a list of 423 projects, the majority having been found thanks to the INTERREG online database (KEEP). The study also includes an exercise in forecasting that lays out five scenarios for the evolution of the collaboration: (Status quo; Regional collaboration; Empowered patients; Strategic networks; Member States’ payer network), based on the premise that the Treaty on European Union and the Treaty on the Functioning of the European Union remain unchanged. These scenarios lead to propositions in terms of public policy. A manual for cross-border project leaders is developed, in order to propose tools for each step in project creation. Certain projects are highlighted in case studies analysing the profitability of cooperation. With regard to France, these include the Cerdanya Cross-Border Hospital, the TRISAN project, hospital cooperation in the Belgian Ardennes, the Forbach-Völklingen Cardiology Partnership, and the IZOM project (Integratie Zorg Op Maat: tailored healthcare).
The study’s conclusions provide seven lessons on cross-border cooperation in healthcare matters (CBHC – cross-border healthcare):

1.     “Cross-border healthcare initiatives are more effective in regions where ease of cooperation is already established, e.g. due to similar welfare traditions or close historical ties.

2.     Support should be given to key players such as regional policy-makers or hospital managers to reduce transaction costs of cross-border healthcare. The toolbox developed in this study can provide help.

3.     There are several scenarios for future cross-border healthcare, one of the most realistic ones being one which builds regional networks oriented towards addressing local and regional needs.

4.     Regional networks are likely to represent a low-cost option, but the downsides are that they are likely to remain small-scale and they may create inequities by not benefiting all regions equally.

5.     Top categories of cross-border healthcare initiatives to receive EU-funding over the past 10 years are 1) knowledge sharing and management, and 2) shared treatment & diagnosis of patients.

6.     Collaborations such as high-cost capital investments and emergency care tend to have more discernible economic and social benefits, but require more formalised terms of cooperation.

7.     Although information on the effectiveness and sustainability of current cross-border healthcare initiatives is scarce, funding of CBHC projects could help achieve these aims.”